The research team conducted 20 in-depth consultations in two regions with participants who are directly involved in the management of the cold chain, including maintenance, making financial decisions related to maintenance, or direct users of the cold chain (Table 1). After data collection, the research team led data synthesis and insight identification to serve as a starting point for the co-creation workshops. Fourteen people participated in the online co-creation workshop, and 20 people participated in the in-person workshop including five of the same participants from the online workshop (four researchers and one Niger-based project supply chain technical expert). Ten additional stakeholders participated in the validation meeting.

Table 1 Participants of in-depth consultations

Results of data collection and synthesis identified three emergent themes.

Themes and insightsTheme 1: agility of the system and optimization of resources

The study showed that the cold chain maintenance system in Niger is based on a hierarchical organizational structure, which leads to internal communication challenges between various stakeholders, a lack of agility, and inefficient use of available resources. The research team identified three main insights under this theme.

While the government has a maintenance department and trained technicians, the system is highly dependent on partners for funding to support maintenance activities. According to the research, each year, the government immunization teams develop workplans, which include preventive and corrective maintenance, and submit the plans to partners such as UNICEF, Gavi and WHO to request financial and material support. The availability of funding is then tied to partners’ priorities and may not be available for much-needed maintenance activities. Dependence on external partners creates a system that is rigid, slow, and unable to respond quickly and efficiently to maintenance needs.

Communication between stakeholders involved in the CCE maintenance system lacks clarity and structure. The health system in Niger has a clear chain of command from national to regional and district levels; despite this clear organizational structure, communication related to the CCE is ad hoc and unstructured. Many participants expressed that when faced with problems they were often unsure who they should turn to. For example, versatile maintenance technicians (TPMs) report directly to the Maintenance and Repair Service for Operating Equipment (SERMEX), which should be the first point of contact when a TPM faces a maintenance problem that cannot be resolved. Yet, the consulted TPMs and SERMEX explained they were rarely in contact with each other.

Health workers at facilities are diligent about collecting cold chain temperature data and recording on paper temperature logs twice daily as per government policy. This data is then collated into a monthly report and kept on site; it is shared more broadly only if regional or national staff conduct supervision activities. Participants indicated that they do not have a clear understanding of the utility of cold chain temperature data for any management or long-term planning purpose. The data is collected because it is a daily task and required by government policy, yet the data is not used for broader planning decisions. Participants indicated that they react to the data that show significant temperature excursions by moving vaccines to a different CCE, yet the action taken is typically not documented, and it is not linked to a request for maintenance. The absence of a clear system or guidelines on how to effectively use temperature data contributes to the lack of optimization of available resources.

Theme 2: prioritizing cold chain

The findings indicated that the immunization program effectively de-prioritizes cold chain management and maintenance, as described in two insights.

Partners are an integral part of the cold chain system in Niger, and their contributions are important and much needed. However, many research participants working at the district or facility level felt that the partner contributions were too centralized at the national and regional level and thus did not accurately respond to the true needs at the local level. One example provided was related to the type of CCE procured for district and facility levels that has fans that easily get dusty in the environment and cause the equipment to fail if not regularly cleaned. Another example of a centralized decision is the procurement of spare parts, typically done at the central level for economies of scale yet unresponsive to the urgency of the need for the spare parts at the sub-national levels. Participants from the regional level expressed preference for managing spare parts themselves, from procurement to distribution, instead of depending on the central level.

A second finding within cold chain prioritization is that cold chain management and maintenance is not seen as an independent priority of the health system. Rather, it is closely tied to immunization activities and service delivery. This link, while logical given CCE is primarily stored for vaccines, currently translates to training that is not specific enough to address the varying maintenance tasks required of staff to perform. For example, health workers in facilities should prioritize preventive maintenance, while technicians need more technical skills and knowledge to be able to diagnose problems and replace spare parts. Participants shared that training is available yet not adequately focused on specific tasks for different staff.

Theme 3: knowledge sharing across the system

The final theme reflects the need for more tailored training, knowledge sharing, and clarification of roles and responsibilities across all team members who are involved in managing and maintaining CCE.

There is a discrepancy between the expectations that staff have for training and knowledge sharing, and what is actually provided to them. Regional and national level officers report that training is provided to sub-national level staff, but it may not be in the traditional seminar-style training. District level CCE technicians and immunization officers reported feeling that they do not receive adequate training on CCE maintenance. By their own admission, they often patch equipment as a quick fix based on their experience instead of a formally structured approach, such as by following a standard operating procedure. The technicians also indicated that they often rely on each other for support when faced with a problem they cannot fix, although in an ad hoc manner. While peer-to-peer support is valued and important, respondents highlighted a need for more tailored training to repair equipment. Results show that there is not a common understanding of what training is required or available for different team members at the different levels of the system, and that the preference is for a variety of training methods (seminars, mentorship, peer-to-peer support) to be available.

Limited understanding of roles and responsibilities and how different team members should collaborate results in inadequate sharing of information and inefficient use of human resources. While staff understand their individual role within the cold chain maintenance system, results show that there is not a clear connection made between the different roles and how they support each other. A concrete example of this is that the cold chain technicians do not receive temperature reports; the reports are only shared with the departmental immunization coordinator and regional immunization coordinator. Another example was a disagreement on who is responsible for preventive maintenance, the technicians or the health facility staff, each one putting the responsibility on the other. This confusion of roles and responsibilities is demotivating for staff.

Concepts for potential solutions

During both co-creation workshops, participants responded to seven “How Might We” questions that were designed to convert problems identified through data collection and synthesis into design challenges (Table 2). Through this process, participants identified an initial 15 potential solutions to explore. Participants then aligned around four final concepts as feasible and the most impactful ideas to explore for improving the Niger cold chain maintenance system, as described here.

Table 2 “How Might We” questions designed for the co-creation workshopConcept 1: create an online platform to connect people involved in cold chain maintenance and to track and share knowledge across regions

This concept was designed to address the challenge of communication channels between all stakeholders, to promote knowledge sharing, and to reinforce the use of temperature data. Insights implied that structured communication between all stakeholders is necessary to ensure that the system is functioning properly and that information is being shared. It is important to create alternate systems of direct communication that are more responsive and can quickly address questions that arise.

This proposed platform would allow stakeholders to gather all information related to CCE in one place, ensuring not only good documentation but a more agile and individualized approach to accessing resources, whether in the form of technical guidance or knowledgeable people. While the participants had different ideas on the type of information that should be included on the platform, the common element was to have an easily accessible digital tool to centralize all information. The expectation with this concept is that the use of a digital platform would put the information at the fingertips of all those who need it, without any of the problems associated with traditional communication methods (email, WhatsApp, etc.).

Concept 2: develop different technical resources on CCE best practices and knowledge

This concept addresses knowledge sharing and the importance of creating self-sustaining, locally managed training methods. Participants agreed that the technical resources should be in a variety of material formats, such as: printed and physical materials that can be used on a daily basis for quick problem solving with visual representations; videos that can show step-by-step instructions for resolving daily and common challenges with CCE and can be shared and stored on the online platform; and a training module with theoretical and practical knowledge and activities to ensure new staff feel confident to do their job. This concept would enable access to materials that were developed within the system, providing valuable knowledge that is tailored to the specific context to support people to be able to do their job. Participants did not explore how to effectively develop and manage technical materials to ensure their utilization; this aspect would be further explored through prototyping.

Concept 3: use gamification and friendly competition to motivate staff to value maintenance

This concept addresses the issue of motivation to conduct preventive maintenance on CCE. This explores the idea of creating weekly challenges among health workers in districts or regions using different formats, such as quizzes on maintenance, collection of temperature data, or a task checklist to be completed. To create a friendly competition for this, scores can be shown on a dashboard on the platform periodically as designated useful by users. Participants identified this as a way to maintain frequent communication and ensure that there is no loss of information. Offline activities can include recognizing a maintenance “super star” at the end of the year to celebrate achievements, bring together all stakeholders, and recognize efforts. This type of weekly competition and annual celebration and recognition is a way to strengthen the ties between stakeholders and motivate individuals to remain committed to preventive maintenance.

Concept 4: develop and use a real time tracking system of maintenance activities

This concept is related to the questions of how to more effectively use temperature data and reports to anticipate maintenance needs and to create a more agile maintenance system. The concept is a system that reminds people in charge of preventive maintenance of the daily and weekly tasks required for the CCE, such as collecting temperature data, cleaning the CCE, and removing dust from the fans. This would contribute to a more structured system to guarantee that the activities and tasks to maintain the CCE are performed on time.